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IIR 12-118 – HSR&D Study

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IIR 12-118
Women Veterans Cohort Study 2
Sally Haskell MD
VA Connecticut Healthcare System West Haven Campus, West Haven, CT
West Haven, CT
Funding Period: July 2014 - September 2019

BACKGROUND/RATIONALE:
The proportion of women in the military, their roles, and their exposure to combat changed dramatically during Operation Enduring Freedom, Operation Iraqi Freedom and Operation New Dawn (OEF/OIF/OND). With a young cohort of returning Veterans, VHA must focus on prevention. Strategies that VHA develops will reduce the burden of chronic disease faced by individual Veterans and by the healthcare system. Understanding the prevalence of disease by gender, and risk factors for developing disabling conditions, is of paramount importance in VHA's ability to create programs that are specific to women and to mitigate disparities in healthcare and health outcomes for women Veterans. Women Veterans have higher risks of musculoskeletal conditions and chronic pain than men, and poorer control of cardiovascular risk factors. Women Veterans are using VHA for mental healthcare yet little is known about women's experiences with these services. This study will provide a better understanding of experiences and needs of women Veterans for preventive services.

OBJECTIVE(S):
In WVCS 2, we will expand on WVCS 1, and use the Electronic Health Record Cohort of all VA enrolled OEF/OIF/OND Veterans, and an expanded prospective survey cohort of OEF/OIF/OND Veterans to identify longitudinally, the 1) predictors of, 2) psychiatric and psychosocial moderators of, 3) treatment patterns for, and 4) barriers to care for painful musculoskeletal conditions, mental health conditions, and CVD risk uniquely experienced by women Veterans. Our aims are to 1) determine the pattern of disease onset and progression among women OEF/OIF/OND Veterans compared to men, 2) determine the unique psychiatric and psychosocial moderators of disease progression for women OIF/OEF/OND Veterans, 3) determine unique care patterns for women OIF/OEF/OND veterans, and 4) determine the barriers to care that arise for women Veterans.

METHODS:
We created an electronic medical record (EMR) cohort of male and female Veterans from the OEF/OIF/OND roster and VA electronic administrative and clinical data, and supplemented the data in this cohort with a prospective survey. As of June 2017, the EMR-based cohort includes administrative and clinical data from the Corporate Data Warehouse (CDW) for over 1.2 million Veterans. The prospective baseline survey has been completed by 1138 Veteran volunteers so far. A follow-up survey is being distributed.
WVCS 2 is a mixed methods study focusing on longitudinal evaluation of health outcomes associated with three major areas, musculoskeletal pain, cardiovascular risk, and mental health in women Veterans. Using data from the EHR Cohort, data from the Survey Cohort and information from telephone interviews, we will determine patterns of disease onset and progression in women Veterans for these three major areas.
The main research methods will include, 1) collection and analysis of existing and newly available VA electronic health record and administrative data, 2) additional surveys to an expanded catchment area to include Los Angeles, CA and Durham, NC, in addition to the original WVCS wave 1 catchment areas of Indiana and Illinois and the six New England States, and 3) performance of one-on-one telephone interviews from 4 Women's Health Practice Based Research Network sites (West Haven CT, Los Angeles CA, Durham NC and Northampton MA VAs) to obtain important qualitative data to understand more about OEF/OIF/OND women Veterans' experiences with VA specialty care for musculoskeletal, cardiovascular, and/or mental health conditions.

FINDINGS/RESULTS:
Dr. Haskell's paper "Incident Cardiovascular Risk Factors among Men and Women Veterans after Return from Deployment" (19) was shared with the VA-DoD Health Executive Committee, Women's Health Work Group. The steep trajectory of CV risk in both men and women Veteran, with higher rates among Black women and those with Depression were highlighted. Because women Veterans are more likely to identify as racial/ethnic minorities than men Veterans, and because of high rates of depression among women Veterans, these results were considered important for tailoring preventive strategies to meet the needs of women Veterans. The paper significantly impacted the decision of the HEC Women's Health Workgroup to pilot a women's health specific transition assistance program.
This pilot program aims to educate women Veterans about VA Women's Health Services and improve enrollment rates of women in VA care in order to target cardiovascular prevention, among other end points. Our work has also been shared with the VA-American Heart Association Go Red Partnership-which is an ongoing effort to raise awareness of heart disease among women Veterans.
Dr. Driscoll's paper "Trauma, Social Support, Family Conflict, and Chronic Pain in recent Service Members: does gender matter" helped delineate the importance of social support for women with Chronic pain and formed the nidus for her pilot project-that is currently supported by a VISN 1 CDA award-and is testing the implementation of a peer support pain management program for women Veterans. The program is already achieving significant success. In addition we have published several other papers: "Incidence of Mental Health Diagnoses in Veterans of Operations Iraqi Freedom, Enduring Freedom, and New Dawn, 2001-2014" and "Examining Gender as a Correlate of Self-Reported Pain Treatment Use Among Recent Service Veterans with Deployment-Related Musculoskeletal Disorders".

IMPACT:
We continue to use the WVCS 2 to continue a longitudinal analysis of gender differences in risk for chronic disease (pain, cardiovascular and mental health conditions) after deployment in OEF/OIF/OND to provide information that will ultimately assist VA in tailoring gender specific prevention and treatment programs.

PUBLICATIONS:

Journal Articles

  1. Lisi AJ, Corcoran KL, DeRycke EC, Bastian LA, Becker WC, Edmond SN, Goertz CM, Goulet JL, Haskell SG, Higgins DM, Kawecki T, Kerns RD, Mattocks K, Ramsey C, Ruser CB, Brandt CA. Opioid Use Among Veterans of Recent Wars Receiving Veterans Affairs Chiropractic Care. Pain medicine (Malden, Mass.). 2018 Sep 1; 19(suppl_1):S54-S60.
  2. Edmond SN, Becker WC, Driscoll MA, Decker SE, Higgins DM, Mattocks KM, Kerns RD, Haskell SG. Use of Non-Pharmacological Pain Treatment Modalities Among Veterans with Chronic Pain: Results from a Cross-Sectional Survey. Journal of general internal medicine. 2018 May 1; 33(Suppl 1):54-60.
  3. Haskell SG, Brandt C, Burg M, Bastian L, Driscoll M, Goulet J, Mattocks K, Dziura J. Incident Cardiovascular Risk Factors Among Men and Women Veterans After Return From Deployment. Medical care. 2017 Nov 1; 55(11):948-955.
  4. Driscoll MA, Higgins D, Shamaskin-Garroway A, Burger A, Buta E, Goulet JL, Heapy A, Kerns RD, Brandt CA, Haskell SG. Examining Gender as a Correlate of Self-Reported Pain Treatment Use Among Recent Service Veterans with Deployment-Related Musculoskeletal Disorders. Pain medicine (Malden, Mass.). 2017 Sep 1; 18(9):1767-1777.
  5. Han L, Allore H, Goulet J, Bathulapali H, Skanderson M, Brandt C, Haskell S, Krebs E. Opioid dosing trends over eight years among US Veterans with musculoskeletal disorders after returning from service in support of recent conflicts. Annals of epidemiology. 2017 Sep 1; 27(9):563-569.e3.
  6. Bastian LA, Driscoll MA, Heapy AA, Becker WC, Goulet JL, Kerns RD, DeRycke EC, Perez E, Lynch SM, Mattocks K, Kroll-Desrosiers AR, Brandt CA, Skanderson M, Bathulapalli H, Haskell SG. Cigarette Smoking Status and Receipt of an Opioid Prescription Among Veterans of Recent Wars. Pain medicine (Malden, Mass.). 2017 Jun 1; 18(6):1089-1097.
  7. Breland JY, Phibbs CS, Hoggatt KJ, Washington DL, Lee J, Haskell S, Uchendu US, Saechao FS, Zephyrin LC, Frayne SM. The Obesity Epidemic in the Veterans Health Administration: Prevalence Among Key Populations of Women and Men Veterans. Journal of general internal medicine. 2017 Apr 1; 32(Suppl 1):11-17.
  8. Burg MM, Brandt C, Buta E, Schwartz J, Bathulapalli H, Dziura J, Edmondson DE, Haskell S. Risk for Incident Hypertension Associated With Posttraumatic Stress Disorder in Military Veterans and the Effect of Posttraumatic Stress Disorder Treatment. Psychosomatic medicine. 2017 Feb 1; 79(2):181-188.
  9. Ramsey C, Dziura J, Justice AC, Altalib HH, Bathulapalli H, Burg M, Decker S, Driscoll M, Goulet J, Haskell S, Kulas J, Wang KH, Mattocks K, Brandt C. Incidence of Mental Health Diagnoses in Veterans of Operations Iraqi Freedom, Enduring Freedom, and New Dawn, 2001-2014. American journal of public health. 2017 Feb 1; 107(2):329-335.
  10. Altalib HH, Fenton BT, Sico J, Goulet JL, Bathulapalli H, Mohammad A, Kulas J, Driscoll M, Dziura J, Mattocks K, Kerns R, Brandt C, Haskell S. Increase in migraine diagnoses and guideline-concordant treatment in veterans, 2004-2012. Cephalalgia : an international journal of headache. 2017 Jan 1; 37(1):3-10.
  11. Trentalange M, Bielawski M, Murphy TE, Lessard K, Brandt C, Bean-Mayberry B, Maisel NC, Wright SM, Allore H, Skanderson M, Reyes-Harvey E, Gaetano V, Haskell S, Bastian LA. Patient Perception of Enough Time Spent With Provider Is a Mechanism for Improving Women Veterans' Experiences With VA Outpatient Health Care. Evaluation & the health professions. 2016 Dec 1; 39(4):460-474.
  12. Slane JD, Levine MD, Borrero S, Mattocks KM, Ozier AD, Silliker N, Bathulapalli H, Brandt C, Haskell SG. Eating Behaviors: Prevalence, Psychiatric Comorbidity, and Associations With Body Mass Index Among Male and Female Iraq and Afghanistan Veterans. Military medicine. 2016 Nov 1; 181(11):e1650-e1656.
  13. Kroll-Desrosiers AR, Skanderson M, Bastian LA, Brandt CA, Haskell S, Kerns RD, Mattocks KM. Receipt of Prescription Opioids in a National Sample of Pregnant Veterans Receiving Veterans Health Administration Care. Women's health issues : official publication of the Jacobs Institute of Women's Health. 2016 Mar 1; 26(2):240-6.
  14. Volkman JE, DeRycke EC, Driscoll MA, Becker WC, Brandt CA, Mattocks KM, Haskell SG, Bathulapalli H, Goulet JL, Bastian LA. Smoking Status and Pain Intensity Among OEF/OIF/OND Veterans. Pain medicine (Malden, Mass.). 2015 Sep 1; 16(9):1690-6.
  15. Driscoll MA, Higgins DM, Seng EK, Buta E, Goulet JL, Heapy AA, Kerns RD, Brandt CA, Haskell SG. Trauma, social support, family conflict, and chronic pain in recent service veterans: does gender matter? Pain medicine (Malden, Mass.). 2015 Jun 1; 16(6):1101-11.
  16. Mattocks K, Kroll-Desrosiers A, Zephyrin L, Katon J, Weitlauf J, Bastian L, Haskell S, Brandt C. Infertility care among OEF/OIF/OND women Veterans in the Department of Veterans Affairs. Medical care. 2015 Apr 1; 53(4 Suppl 1):S68-75.
  17. Mankowski M, Haskell SG, Brandt C, Mattocks KM. Social support throughout the deployment cycle for women veterans returning from Iraq and Afghanistan. Social Work in Health Care. 2015 Jan 1; 54(4):287-306.
  18. Goulet JL, Martinello RA, Bathulapalli H, Higgins D, Driscoll MA, Brandt CA, Womack JA. STI diagnosis and HIV testing among OEF/OIF/OND veterans. Medical care. 2014 Dec 1; 52(12):1064-7.
  19. Katon J, Mattocks K, Zephyrin L, Reiber G, Yano EM, Callegari L, Schwarz EB, Goulet J, Shaw J, Brandt C, Haskell S. Gestational diabetes and hypertensive disorders of pregnancy among women veterans deployed in service of operations in Afghanistan and Iraq. Journal of women's health (2002). 2014 Oct 1; 23(10):792-800.
  20. Goyal V, Mattocks K, Bimla Schwarz E, Borrero S, Skanderson M, Zephyrin L, Brandt C, Haskell S. Contraceptive provision in the VA healthcare system to women who report military sexual trauma. Journal of women's health (2002). 2014 Sep 1; 23(9):740-5.
  21. Haskell SG, Bathulapalli H, Pham T, Goulet J, Skanderson M, Driscoll M, Brandt C, Dziura J. Sex differences in patient and provider response to elevated low-density lipoprotein cholesterol. Women's health issues : official publication of the Jacobs Institute of Women's Health. 2014 Sep 1; 24(5):575-80.
  22. Cobb Scott J, Pietrzak RH, Southwick SM, Jordan J, Silliker N, Brandt CA, Haskell SG. Military sexual trauma interacts with combat exposure to increase risk for posttraumatic stress symptomatology in female Iraq and Afghanistan veterans. The Journal of clinical psychiatry. 2014 Jun 1; 75(6):637-43.
Conference Presentations

  1. Kolehmainen C, Stahr A, Pribbenow C, Allard Ca, Altman L, Baier Manwell L, Brandt C, Gerber Me, Havens Ka, Haskell SG, Kerlikowske K, McNeil M, Moyer R, Phelan CH, Washington DL, Veet L, Carnes M, Yano EM. Developing a ‘Community of Practice’ among VA Advanced Fellowships in Women’s Health. Poster session presented at: Society of General Internal Medicine Annual Meeting; 2016 May 11; Hollywood, FL.
  2. Kerns RD, Higgins DM, Goulet JL, Heapy AA, Brandt CA, Haskell S. Differentiating among Veterans who evidence clinically meaningful improvement in pain and those who don’t: A longitudinal analysis. Poster session presented at: American Pain Society Annual Meeting; 2015 May 12; Palm Springs, CA.
  3. Brandt CA, Kerns RD, Higgins DM, Heapy AA, Goulet JL, Haskell S. Mild versus moderate/severe chronic pain: gender differences in biopsychosocial correlates. Poster session presented at: VA HSR&D Enhancing Partnerships for Research and Care of Women Veterans Conference; 2014 Jul 31; Arlington, VA.
  4. Brandt CA, Mattocks KM, Haskell S, Goulet JL, Bastian LA. Gender Differences in smoking status and pain levels among OEF/OIF/OND Veterans. Poster session presented at: VA ORD State of the Art (SOTA) Conference; 2014 Jul 31; Washington, DC.


DRA: Health Systems, Cardiovascular Disease, Musculoskeletal Disorders
DRE: Epidemiology, Prevention
Keywords: Cardiovascular Disease, Gender Differences, Outcomes - Patient, PTSD, Risk Factors, Sexual Trauma/Assault, Social Support, Utilization, Depression
MeSH Terms: none